Around The Practice: The Shifting Treatment Paradigm for Advanced Renal Cell Carcinoma - Episode 9

Choosing Second-Line Therapy for Patients With Advanced RCC

A panel of experts explain what they do within their clinical practices to select second- or later-line therapies for patients with advanced renal cell carcinoma.

Toni Choueiri, MD: One question, which is always I think this is a conundrum. I hear it a lot and I want one minute from each of you here. I hear a lot that folks have been using mostly the most active regimen. First, what should they do? Combinations are here of two drugs and winter is coming. It's very possible- Actually, winter is coming but it's very possible that we can move into three drops from flying COSMIC-313, finish accrual, and that is in a study actually was merged being the sponsor where the two experimental arm are triplet. One idea is always on our mind, should we sequence this agent, or should we start with your best treatment first, Dr Zhang, when do you-What do you do? You follow the data, or you leave something very active to later?

Tian Zhang, MD, MHS: I follow the data and I save things for later. I don't think those two statements are exclusionary, but I do think about the process and the entire multiple lines of treatments when I'm starting upfront therapy, right. I do worry about if and when a patient progresses, how are they resistant? And then what to do next. And so, if I think that a patient, probably we'll see two or three lines of therapy and clinical acumen being very subjective, I will try to limit my most active agent, if you will. I'll save some broader mechanisms like Cabozantinib or Imatinib for later lines and use an Ipi/Nivo [ipilimumab/nivolumab] approach or potentially Axi/Pembro [axitinib/pembrolizumab] approach early so that I can get more mechanistic broadening later on. If I'm really worried that a patient is it's one goes to our earlier point about disease control, if I think what have one hit on target. And if I don't achieve good disease control then I will lose that patient. Then in those cases, I will use my most active agent early on. And so, in my mind, those are the two VEGF/IO combinations, Cabozantinib with Nivolumab, Imatinib with Pembrolizumab. I really want to achieve early disease control then I will use those.

Toni Choueiri, MD: I see. I think you answer for all of us. Let's see if our audience agree with you. Let's take this poll. Would you use everything upfront, or you just are a hoarder, and you try to save some for later? Maybe the most active agent. Knowing there is an attrition rate, we know that from clinical trial, but I think your process Dr Zhang is completely justified.

So far, 13 users, their upfront therapy. Interesting. So far 23 users, upfront therapy. We have one, this Dr Zhang answer, and B. I think I hear that a lot and it's done quite commonly to reserve some single agent or some combo non-IO like Len-Everolimus [lenvatinib-everolimus] to very late line. I see that more commonly. The poll is fine but, in my practice, I think you nailed it.

This transcript has been edited for clarity.